Improving Low-Value Clinical Practices In Murcia: A Healthcare Management Area In Spain

BACKGROUND

The "Do Not Do" movement looks for improving patient safety and reducing health spending by decreasing the prevalence of unnecessary clinical practices through building and launching "do not do" recommendations (DND), although the impact is generally low. The objective of this study is to improve the quality of care and safety of patients assigned to a health management area by reducing the prevalence of DND practices.

METHODS

Quasi-experimental before and after study carried out in a Spanish health management area of 264,579 inhabitants, 14 primary care teams and a 920-bed 3rd level reference hospital. The study included the measurement of a set of 25 valid and reliable indicators on DND prevalence from different clinical areas previously designed, considering acceptable prevalence values of less than 5%. For those indicators that exceeded this value, a bunch of interventions was implemented: (1) inclusion in the annual objectives of the clinical units involved; (2) discussion of results in a general clinical session; (3) educational outreach visits to the clinical units involved; and (4) detailed feedback reports. A second evaluation was subsequently carried out.

RESULTS

In the first evaluation, 12 DNDs (48%) showed prevalence values below 5%. In the second 9 DND of the remaining 13 (75%) improved results, reaching 5 of them (42%) prevalence values below 5%. Thus, a total of 17 of the 25 DNDs initially evaluated (68%) achieved this goal.

CONCLUSION

Reducing the prevalence of low-value clinical practices in a healthcare organization makes it necessary to turn them into easily measurable indicators and carry out multicomponent interventions. Among these, it seems essential that the professionals involved are informed and that training activities are carried out on-site. Improvement cycles are emerging as a useful tool to do this.

[Why is it increasingly difficult to "do the right thing" and to "stop doing the wrong thing"? Strategies for reversing low-value practices]

This manuscript describes the factors that have led to the spread of low-value practices (LVP) and the main initiatives to reverse them. The paper highlights the strategies that have proven to be most useful over the years, from the alignment of clinical practice with "do not do" recommendations, to quaternary prevention and the risks associated with interventionism. Reversing LVP requires a planned process with a multifactorial approach engaging the different actors involved. It considers the barriers to de-implementation of low-value interventions and incorporates tools that facilitate adherence to "do not do" recommendations. Family doctor has an especially relevant role in LVP prevention, detection and de-implementation, due to their coordinating and integrating nature in the patients' healthcare, and because most of the citizens' healthcare demands are managed and resolved at the first level of care.

To do or not to do-balancing governance and professional autonomy to abandon low-value practices: a study protocol

BACKGROUND

Many interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm, and should therefore be de-implemented. Lists of such ineffective, low-value practices are common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be governed and carried out. However, decisions regarding de-implementation are not only a matter of scientific evidence; the puzzle is far more complex with political, economic, and relational interests play a role. This project aims at exploring the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations.

METHODS

Theories of complexity science and organizational alignment are used, and interviews are conducted with stakeholders involved in the governance of low-value practice de-implementation, including national and regional governments (focusing on two contrasting regions in Sweden) and senior management at provider organizations. In addition, an ongoing process for governing de-implementation in accordance with current recommendations is followed over an 18-month period to explore how governance is conducted in practice. A framework for the governance of de-implementation and policy suggestions will be developed to guide de-implementation governance.

DISCUSSION

This study contributes to knowledge about the governance of de-implementation of low-value care practices. The study provides rich empirical data from multiple system levels regarding how de-implementation of low-value practices is currently governed. The study also makes a theoretical contribution by applying the theories of complexity and organizational alignment, which may provide generalizable knowledge about the interplay between stakeholders across system levels and how and why certain factors influence the governance of de-implementation. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. The framework and strategies can thereafter be evaluated for validity and impact in future studies.

Developing a framework to guide the de-adoption of low-value clinical practices in acute care medicine: a study protocol

BACKGROUND

Healthcare systems have difficulty incorporating scientific evidence into clinical practice, especially when science suggests that existing clinical practices are of low-value (e.g. ineffective or harmful to patients). While a number of lists outlining low-value practices in acute care medicine currently exist, less is known about how best to initiate and sustain the removal of low-value clinical practices (i.e. de-adoption). This study will develop a comprehensive list of barriers and facilitators to the de-adoption of low-value clinical practices in acute care facilities to inform the development of a framework to guide the de-adoption process.

METHODS

The proposed project is a multi-stage mixed methods study to develop a framework to guide the de-adoption of low-value clinical practices in acute care medicine that will be tested in a representative sample of acute care settings in Alberta, Canada. Specifically, we will: 1) conduct a systematic review of the de-adoption literature to identify published barriers and facilitators to the de-adoption of low-value clinical practices in acute care medicine and any associated interventions proposed (Phase one); 2) conduct focus groups with acute care stakeholders to identify important themes not published in the literature and obtain a comprehensive appreciation of stakeholder perspectives (Phase two); 3) extend the generalizability of focus group findings by conducting individual stakeholder surveys with a representative sample of acute care providers throughout the province to determine which barriers and facilitators identified in Phases one and two are most relevant in their clinical setting (Phase three). Identified barriers and facilitators will be catalogued and integrated with targeted interventions in a framework to guide the process of de-adoption in each of four targeted areas of acute care medicine (Emergency Medicine, Cardiovascular Health and Stroke, Surgery and Critical Care Medicine). Analyses will be descriptive using a combination of qualitative and quantitative analyses.

DISCUSSION

There is a growing body of literature suggesting that the de-adoption of ineffective or harmful practices from patient care is integral to the delivery of high quality care and healthcare sustainability. The framework developed in this study will map barriers and facilitators to de-adoption to the most appropriate interventions, allowing stakeholders to effectively initiate, execute and sustain this process in an evidence-based manner.